qq-en-2018

R IV IS TAQQ La Qualità e le Qualità in Medicina Generale - Periodico di Ricerca e VRQ in Medicina Generale fondato nel 1996 da SIQuAS-VRQ e SIMG Verona

Senior Assistant Editors: Alessandro Battaggia, Enzo Brizio,Vittorio Caimi, Alessandro Dalla Via, Pasquale Falasca, Sandro International Committee: We b : w w w. r i v i s t a q q . o rg

Girotto, Giobatta Gottardi, Michele Valente, Giorgio Visentin Julian Tudor Hart, Paul Wallace info@rivistaqq.org

In collaboration with http://www.netaudit.org

J T Hart in Verona Photo by M. Baruchello

Special Number in memory of JULIAN TUDOR HART

Rivista QQ, August 2018

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Direzione: Via dell’Artigliere, 16 Legnago (Verona)

Assistant Editors: Marco Grassi, Paolo Quattrocchi, Giulio Nati, Paolo Schianchi, Alberto Vaona

Redazione: c/o OdM di Vicenza,

Managing Editor: Giulio Rigon

Via Paolo Lioy, 13 36100 Vicenza

Senior Editors: Mario Baruchello, Francesco Del Zotti (Science Editor)

Iscrizione Tribunale di Verona n. 1187 del 12.12.95

Proprietario ed Editore: Associazione Qualità Medica

Editor-in-Chief: Roberto Mora

JULIAN TUDOR HART

leader of Italian MG and a profound

THE UNIVERSAL GENERAL

connoisseur of British medicine, shows

PRACTITIONER

with an in-depth and passionate article what he has had on our souls and on our concept of General Practice.

Francesco Del Zotti

Ferdinando Petrazzuoli, member of the

General Practitioner - Verona Italy Netaudit Director www.netaudit.org

We dedicate this special issue to Julian Tudor Hart, who died on July 1, 2018, our inspirational guide, who for decades has honoured us with his friendship and his participation, together with Prof. Paul Wallace, to the the international scientific committee of this magazine. You can read, two articles written

for our magazine titled

and

articles-

interview written by doctors in collaboration with the epidemiologist Pasquale Falasca, on the occasion of his participation in the Congress of Bertinoro.

Mario Baruchello, Gianluigi Passerini and Ferdinando Petrazzuoli are taking part in this celebratory event. A special thanks to the italian GP, dr Giulio Rigon, who edited this newsletter, comes in two versions (Italian, English).

Mario Baruchello, with which few brush strokes , is showing the affective charge of Julian toward our Italian group: we had the pleasure to invite him to some scientific and social events. And Mario, a wellknown photography enthusiast and skilled archivist, has rediscovered for us some photos he portrayed and his drawing.

Gianluigi Passerini, well-known cultural Rivista QQ, August 2018

research network, remembers his figure and his masterly conference at the

in the sitography, his

executive board the European EGPRN

i m p o r t a n t 2 0 0 9 E G P R N E u ro p e a n Congress, in the splendid medieval setting of Bertinoro.

I met Julian Tudor Hart at the 3rd SIMG congress in Florence in the autumn of 1985.

He presented the results of his original experience of GP and epidemiologist of a small village in Wales. His transparencies struck me. While others presented color slides from the standardised format, he presented the data with handwritten black and white transparencies. In them, in addition to the great graphic expertise that I would later have known, the rigor of his method and the power of his commitment were highlighted. The histograms showed the before-after intervention in his community: numbers and percentages of measurement among patients of practices such as the measurement of blood pressure or the Pap test. Simple column diagrams showed increments of more than 40-50%, such for which he commented that the data and the graph spoke for themselves, without the need for refined statistical tests, often !2

useful to mask small "significant"

horizontality in the relationship with

differences only statistically

but clinically

patients. His faith and rigor in recording

insignificant. The simplicity and power of

data and in medical records are better

those transparencies fascinated me and

understood in light of an episode. In Bari

encouraged me to ask him if I could go

(as i said i worked close to

and see him as a medical observer. And so

region, until 1993) as provincial president

I did in March 1986, starting from a town

of Italian Society of General Medicine

of Puglia where I was working (Modugno).

(SIMG) I organised at the end of the '80s

You have a report of mine in the article in

one of the first meetings with the

the sitography entitled "da Modugno al

innovative method of continuous training

Galles". I stayed less than 10 days. A short

"in small groups." We were proud. Julian ,

period that however would have marked

at the end of our meeting told us : "Yes,

my entire professional life.

use a good method, but what you are

The relief of his scientific and social

doing we do not do it anymore." For some

presence in British General Practice can be

years now we have not worked with

deduced from the beautiful necrology

theoretical cases at a table: we take the

appeared on the BMJ (Bmj, 2018).

clinical records with us to the meeting. "

In these next lines I will give you some

He made numerous daily home visits,

snapshots about its versatility: the doctor,

bringing with him the groups of folders

the researcher, the person, the friend, the

related to that house and that family.

character.

Home visits were not just strictly for clinical

Bari, Puglia

problems. At each death he used to go The General Practitioner

home to the widow or widower for homage to the family and to bring comfort

In the clinic he was very meticulous, and

and plan a subsequent visit to the home or

he carefully treated the data recording. He

in the clinic.

would append to a notebook data,

He also impressed his love for the truths

commitments and ideas continuously, and

also uncomfortable. He went to the

in any room of the surgery or home; on

bottom of the diagnostic process of his

that notebook where he occasionally

and his colleagues and he gave report on s

relaxed with drawings and portraits.

to the patients. Only from this attitude

He had a huge wardrobe in the office filled

could grow a extraordinary

with clinical records; every clinical record

General practice of each country: "Be Your

had become big folder after decades. The

Coroner",

secretary handed over the file to the

deaths in General Practice (Hart, 1987)

patients before the visit; this testifies to its

His approach to the entire community of

t e n s i o n t o w a rd s t r a n s p a re n c y a n d

his patients was constant and original. For

Rivista QQ, August 2018

study, in the

an audit of 500 consecutive

!3

example, each year it provided each family

with the Medical Research Council. The

with a Bulletin on the management of the

MRC continuously sent young trainees and

clinic, staff composition, activities and

approved and financed research projects;

workload; with, finally, some statistics on

which has also honored this important

the main diseases and risk factors

body that has shown rare ability: logistically support the MG without

The Researcher

overwhelming it. I myself witnessed the

respect Julian enjoyed in the high spheres

He had been a researcher up to 35 years

of research; and thanks to him I had the

under the leadership of the great

honor of being presented to the famous

Cochrane. Then he decided to embark on

epidemiologists Jeoffrey Rose and James

a challenge. Perform both the work of

Mc Cormick.

MMG and the Epidemiologist together.

Cochrane was a pessimist: "you will not be

The Friend

able to perform both tasks well". His

fundamental and prestigious publications

Since I was 34, Julian turned out to be an

and the love of his patients testify that he

a ff e c t i o n a t e a n d s w e e t l y p a t e r n a l

has won the challenge. This was also

colleague and friend with me and my

thanks to the decisive collaboration of his

family. He was happy to visit Italian

wife Mary who worked in the same group

beauties and cities of art, including the city

as Cochrane as a research secretary and

where I now reside: Verona. But he, of a

who always proved to be a decisive figure.

refined London family, was much more

His epidemiological research has been

enthusiastic when we visited less sparkling

p o s s i b l e b o t h t h a n k s t o r i g o ro u s

places: for example the small towns of

methodology and thanks to the ability of

Basilicata, Puglia or Sicily. Or when he

Julian and Mary to have contact with the

knew and became a friend of simple

entire community. For example, the search

people as in his stay of a few days in

for the relationship between salt in the

Polignano.

diet, measurement of sodium and hypertension, was possible thanks to civic assemblies in the village of miners and door-to-door to each patient's home.

The character and his social commitment

But there was not only capacity for

Julian has continuously expressed his spirit

adherence to the local spirit. There has

of independence: his social and political

also been an ability to hold relationships

choices have always been counter-current,

with the highest levels of British

on the side of the humble. One example

epidemiological research and in particular

of the miners' strike in Wales. He, General

Rivista QQ, August 2018

!4

Practitioner of a small country of miners of

Conclusion

Wales, during the famous strike of

1984-1985, supported their cause.

Julian with his life has taught us that you

As? The miners were on their last legs: for

can not be a good doctor and good

example they were forced to cut many of

epidemiologist without an ability to get

the trees in their hills to warm up (it was

involved, and to involve the individual and

the revelation when I asked him: "why,

the community. Patients do not offer

Julian, in the valley one of the two sides is

collaboration to complex research projects

without trees?"). In those dramatic months

without there being not only respect but

Julian worked for an international

also a sort of love towards their doctor.

fundraiser between

doctors and

epidemiologists (eg by sending magnificent postcards made by him: he

was a brilliant designer) while his wife

Julian Tudor Hart reminds me of one of the

organised in front of his house huge tables

founders of modern medicine: Rudolf

to feed the population. In short, in a world

Wircow. The German scientist, besides

where doctors often love to get on the

being a champion of medical research,

wagon of the winners, Julian Hart, a true

was always politically engaged and often

doctor, climbed onto the chariot of the

an antagonist of dominant power. He

humble and the losers.

dedicated himself to assisting everyone,

Moreover, in an age when myopic

regardless of their economic possibilities.

nationalisms are imposed, we like to

According to the well-known medical

remember that Julian was a convinced

historian Nuland he was "the main

internationalist. His solid political base

exponent of the thesis according to which

fuelled the drive to know the international

man is the product of the situation in

dynamics of the profession. He was an

which he lives. Environmental influences,

official consultant for some national health

occupation, inheritance and even social

ministries and an informal consultant for

class played a decisive role for Wircow ".

many national movements of Gps.

Following the same words of Wircow:

"scientific knowledge is required of the multiple and varied relationships of the single thinking individual with the world in constant change". Nuland concludes: "According to Wircow, man had to be studied not only under a microscope, but also with a macroscopic vision connected to the universal vision of his humanity".

Rivista QQ, August 2018

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Replace the word "microscope" and "macroscopic" with the words "general

h t t p s : / / a p p . b o x . c o m / s / bmkidjuxbfj27jini1bmy8hg6rbgxfdq

practitioner", "community doctor", "epidemiology": you will be introduced to the world of Julian Tudor Hart

Bibliography - BMJ Obituary(July 2018) : Julian Tudor

Sitography:

Hart: visionary general practitioner who

Wikipedia - Julian Tudor hart https://en.wikipedia.org/wiki/Julian_Tudor_Hart

introduced the concept of the “inverse care law” -

British

Medical Journal

2018;362:k3052 Hart J: Che Uso fare della Ricerca in Medicina

La qualità e le qualità in

Medicina generale (Maggio 2003)

- Nuland, Sherwin storia della medicina, ed italiana a cura Mondadori (1988)

https://issuu.com/rivistaqq/docs/qq16it

- Hart Julian , Humphreys C, e your own Interviews and article on Julian Hart at

coroner: an audit of 500 consecutive

the EGPRN conference of Bertinoro on

deaths in a general practice. British

www.rivistaqq.it at Link: https://rivistaqq.org/

Medical Journal (Clin Res Ed). 1987 Apr.

wp/wp-content/uploads/QQ-IT-030-10-2009.pdf:

Julian Tudor Hart :“La ricerca per la medicina generale: dati poveri da numeri significativi o dati consistenti da persone “insignificanti”?”

Del Zotti F “I memorabili workshop di Bertinoro su Netaudit e fragilità, alla presenza di Hart e Dean” a

cura

di Livia

Lo

Presti, Anna

Marcone, Agnese Accorsi, e Dr.Pasquale Falasca Unità di Epidemiologia Ricerca & Sviluppo , Ravenna.

“Il concetto di fragilità per favorire l'equità sanitaria: il contributo di Julian Tudor Hart “ Del Zotti F. “da Modugno al Galles” rivista SIMG -1 - 1988 Rivista QQ, August 2018

!6

JULIAN TUDOR HART WAS A FRIEND OF OURS

On the other, the social commitment preferring the Scottish community of poor and oppressed miners to Glincorrwg to

Mario Baruchello General Practitioner, Vicenza Italy

We were a lot far January 25, 2003 to welcome him with his face engraved by the winds, framed by a beard to the Solzhenitsyn and the ever-present nostromo bleu cap to the 12 Apostles in the heart of Verona.

Franco Del Zotti had invited him; we wanted to make him feel, with the strength of our affection, the professional esteem and the deep respect for having been a country family doctor who had revolutionized with determination, with constant sacrifice, with the coherence of a lifetime the whole evolution of general practice.

On the one hand the scientific method of research / action that earned the dignity of specialty to a branch of medicine until now

neglected. The diaries with the

pressure data of all his patients, compiled with the indefatigable and disinterested help of his wife, of which he showed us an original, are the faithful testimony of the careful study of a stable population operated in a longitudinal way. to understand, with the method of careful compilation of the medical records, that prevention was the real anticipatory medicine capable of delaying chronic cardiovascular diseases and saving lives.

Rivista QQ, August 2018

the magnificence of researcher in epidemiology with Archie Cochrane and Richard Doll.

A biopsychosocial vision that combined with the use of initiative medicine extended the routine consultation to the entire patient experience in a populationbased approach. This is how he demonstrated in his community a 28% re d u c t i o n i n m o r t a l i t y i n t re a t e d hypertensive patients, compared to untreated patients. * While we fed him pasta and beans, cotechino and pearĂ watered by the best amarone he resisted telling us his life and smiling to his wife nearby. Meanwhile, with a sure stroke of pen, he portrayed us in a drawing in which the assembly of our caricatures had nothing to be envied by the stylistic construction of the anatomic lesson of the dr Tulip realized by Rembrand in 1632.

Only the dead body was missing wich had been replaced by the table set in an epicurean banquet in the most famous restaurant in Verona under the arches of the Roman Arena.

In a picture, which portrays us in a group, I see friends who will open as long as I live the doors of our house and next to my wife that evening stands the serene smile of Claudio Carosino gold medal for civil valor that gave life to real medicine .

!7

* J T Hart The Lancet 1970 Elsevier, Semicontinuos screening of a whole community for hypertension Postilla: J Tudor Hart wrote, before having the General Practice Chair in 1976 in Manchester, "the general family doctor studies what is not needed at the hospital at the University, in the hospital he learns a medicine that is not that of real life and in the end it must be formed with many autonomous paths to juggle everyday family and community medicine ".

You recognize: Mario Baruchello, Franco Del Zotti, Gigi Passerini, Giuseppe Parisi, Julian Tudor Hart, Giorgio Visentin

Rivista QQ, August 2018

!8

JULIAN TUDOR HART, A MAN AND A

introduced to him by my friend and

MEDICAL DOCTOR/GENERAL

teacher Hugh Charles Faulkner.

PRACTITIONER WHO WILL ALWAYS STAY WITH US

By the way, on that occasion Julian [and H u g h ] i n t ro d u c e d m e t o A rc i b a l d Cochrane (Julian’s teacher when Julian worked with him in Epidemiology and

Gianluigi Passerini

Statistics at the Medical Research Council

M.D./G.P. Italian Member EQUIP (European Society for Quality and Safety in General Practice/Family Medicine)

where Cochrane was the Director). This was a special honour for me, a special honour in my life.

Starting from the higher echelons of London society and university he then decided to move to a real and complex/

He might not be with us anymore but Julian is somebody who will always remain among us and will be remembered in the history of medicine.

J u l i a n ’s s p i r i t , i n s p i r a t i o n a n d knowledge will be forever present in the f u t u re o f G e n e r a l P r a c t i c e / F a m i l y Medicine, as a corner-stone in medical thinking.

I cry for his departure even though if I know that he doesn’t want anybody to do it but just to continue along his way, because he really was a “visionary and unique and exemplary human being and medical thinker”.

Julian was (and still is)

a doctor, a

General Practitioner, a researcher, an artist, a poet, a “specially human” human person devoted to population science and a socialist/communist (Member of the Labour Party). He always had a positivistic approach to life and to people.

I met him at first at the Royal College of General Practitioners in London, Rivista QQ, August 2018

complicated surgery in the coal mining village of Glyncorrowg (Wales).

For him, a visionary, it was a particular aim/challenge to be GP in a place where health care was more needed and necessary.

To explain this move I will start with the story of how I engaged with him.

When I went to Glyncorrowg for the first time (around 1982-1984), it was with my dearest friends Hugh and Marian Faulkner.

Hugh, my Mentor GP who taught me many things in London and then in Italy. Julian then suggested to my young son to go and buy an ice cream at the the local ice cream shop, which was run by Italians.

The shop name was “Gelateria La Veneta (the Veneto Ice Creamery)”. The owner asked my son where in Italy he was from to which he replied: “from Sondrio”.

He also said: “But we also come from the same town where we run an ice cream shop with exactly the same name”. This was quite a coincidence. !9

Their shop actually was my favourite ice creamery in my youth and then moved to

nobody there to check their blood pressure, for instance.

Wales because UK-based relatives in that

Julian and Mary’s house looked like an

little coal mining valley told them that

Institute of Epidemiology & Clinical

there was much more to do than in

Research: I remember a large room totally

Sondrio.

filled with books, papers, hand-written

At that time miners worked there in

pages and files of data. A research fellow

their thousands. It was about a decade

in the field, Mary worked in cooperation

later that the British government decided

with Julian who gathered the data in

to close them all.

everyday activity in the surgery.

In the times that followed, in the battle

What mostly and at first (among many

that the miners’ put up against the poverty

other things and ideas/practices in that

they faced, Julian’s wife Mary became one

surgery) hit me was the famous method of

of the leaders of women against the

“Family Clinical Records” settled up and

closure of the mines.

used by Julian: he used to keep

This is just to make you understand

[paper]clinical records archived together

where they had moved and why: to offer

for each family instead of individually, the

medical care to one of the poorest

father’s one containing the ones of wife

population in the UK.

and siblings.

It was a mixture of political and medical

In this way cardiovascular risk factors

reasoning for Julian to leave London’s

could be studied inside each risk factors

higher social strata to start putting in

unit, i.e. each family/household.

practice his political (socialist/communist)

Julian and Mary gathered and

and medical ideas as the raison d’etre of

p u b l i s h e d p re v i o u s l y n o n - e x i s t e n t

his professional life.

epidemiological and clinical data on

He started General Practice carrying out epidemiological approach, studying

cardiovascular risk factors in a “really general and unselected” population.

cardiovascular risk factors in his

He was the first GP who wrote a book

population, then screening them with the

on Hypertension. I still have a copy, which

aim of reducing the incidence among

he wrote in for me, as well as of others of

them of “a kind of unprivileged” people.

his books. This book was considered as a

This was the so called anticipatory

reference textbook and was read also by

preventive care.

specialists, who used to take it as

Smoking, drinking, poor and fat diet where typical of that area and of that population of mine workers. There was

reference and accept/appreciate it, even if it had been written by a GP. In 1960-1970 it was not usual among GPs to check blood pressure preventively

Rivista QQ, August 2018

1! 0

in every adult patient as Julian Tudor Hart

The second started from a paper, he

did. He also did it to help with the

published on The Lancet, in which he

research, demonstrating a lowering in

made the proposal that Medical Students

cardiovascular morbidity in his own

should be trained as General Practitioners

assisted population.

and not as specialised Medical Doctors,

Among his other contributions, I want to

i.e. they should be clinical doctors and,

recall two other books, from the period

only afterwards, should they be trained to

after his retirement:

become specialists. Otherwise they would

A new kind of doctor: a book of a

have lost the clinical vision of medicine, as

realistic visionary, the first written after his

that usually happens when students are

retirement, in which he asserted the

only exposed to hospital-based specialist

partnership among doctor and other

learning.

health operators to create and develop a better forms of health care

His paper was followed by a discussion, also involving American Medical Teachers.

The political economy of heath care, a

The issue is still valid, as the priority need

clinical perspective: there he wrote about

in providing the world with effective care

the way finances were used (and could

passes through a well structured and

better be) in the N.H.S., dealing with

clinically approached effective Primary

determinants of health outcomes in the

Care, an assertion on which there is more

British National Health Service and how

and more worldwide agreement. This is

they could be better achieved in the 21st

especially the case after the increase of

century.

medical care’s need in the face of a huge

The many books he wrote inspired a great deal of social, political and medical debate in the UK and all over the world.

Two fundamental issues in his life and publications have been crucial in his inspiration and proposals:

increase of its less and less affordable specialised costs.

Julian was also a real eclectic artist, not only a naturally talented designer and painter.

In Glyncorrowg he asked my son his

The inverse care law

name, took a glass and in a while, using a

Basing medical education on General

pyrography method, wrote his name, with

Practice instead of on hospital care The first is universally known (who has

a drawing of a couple of sparrows (as our surname means little sparrows), on it.

health problems has no access to

There is something else which he

resources and vice versa) and since now

became well-known to his friends for and

on I would suggest we name it “Julian

which we keep: his famous Christmas

Tudor Hart’s Law”.

Cards.

Rivista QQ, August 2018

1! 1

For decades at every Christmas he used to send friends a drawing with a written comment on the previous and forthcoming year. These were were

high quality

artworks and a sign of close and continuing friendship and relationship.

At every Christmas we were eager to imagine what would be the topic of that year! The 2017 one (see picture) encloses the whole of his history.

When Julian and Mary come to spend a holiday period at our house by Lake of Como many years ago, they would have come again with pleasure but he was already heavily suffering from chronic low back pain. They left a bottle of whisky and in the fridge a few very tiny little bottles of Martini, which are still there and there will remain.

I feel lucky and deeply honoured to have had the chance to meet Julian Tudor Hart. He will remain a corner-stone in the experience of my medical history and profession.

ONE OF THE GIANTS OF GENERAL PRACTICE OF THE TWENTIETH CENTURY PASSED AWAY LAST JULY

Rivista QQ, August 2018

Baruchello ,Hart, Gorini, Mazzi ,Visentin, Carosino, Vettore, Campanini, Passerini, Falasca, Del Zotti 1! 2

Ferdinando Petrazzuoli

The key to the success of his research,

European General Practice Research Network

which led him to international fame, was

Executive Board & Educational Committee

the remarkable and sustained cooperation of his 2,000 patients, given in return for his

Doctor Julian Tudor Hart is known to have highlighted for the first time one of the problems of modern European health systems, the so-called "inverse care law", published in Lancet in 1971, according to which “communities most in need of good healthcare are those least likely to receive it�.

Born in London, he studied medicine at the University of Cambridge. Working with a Welsh mining community had been Tudor Hart's ambition since he started his medical career in 1952. The opportunity came nine years later when he moved to Glyncorrwg, a village in the Afan Valley, and he set up a research practice in what was little more than a wooden shed. Mary Thomas, a medical researcher of equally radical convictions, followed him and in 1963 became his second wife.

He also gained research experience working alongside epidemiologists who were to become illustrious figures in the field: first, Richard Doll at the London School of Hygiene and Tropical Medicine; subsequently, in a move that took him to south Wales, Archie Cochrane at the then Welsh National School of Medicine.

This background in epidemiology taught him to investigate the relationship between his patients' lifestyle and their poor health. He pioneered much of what is now accepted as routine preventive care.

Rivista QQ, August 2018

unswerving commitment to them.

He was a keen supporter of the universalism of the United Kingdom National Health Service (NIH). Even after retirement he continued to be a researcher and obtained honorary positions at the universities of Cardiff, Glamorgan and Glasgow.

In an increasingly technological and mechanistic medical world in which we now live, we need people like Julian more and more. We must remember that artificial intelligence and technology are not always the appropriate response and we must strive to maintain compassion, human dignity and give importance to an approach focused on family and patient care.

I was lucky to have met him at the meeting of the EGPRN (European General Pratice Research Network) in Bertinoro in May 2009, where we invited him to give a lecture. When I asked him what academic qualifications and affiliations I had to write in the official program next to his name, he simply replied: "doctor of experimental life".

The general Italian medicine that has no heroes, not because there are none, but because it is not able to identify them mainly because of the crumbling of its traditional and genuine values by the public institutions and their substitution 1! 3

with merely economic values, should pay homage to a shining figure like Julian Tudor Hart.

We will miss him a lot.

Rivista QQ, August 2018

1! 4